Program Applications and Forms

Purdue Pharma Patient Assistance Program: Contact program

Medications

Eligibility Requirements

Must have no prescription insurance, be ineligible for any state and federal programs

Those with Part D Eligible?

Considered on exception basis

Income

At or below 139% of FPL

Diagnosis/Medical Criteria

Not specified

US Residency Required?

Must be US citizen or legal entrant

Application

Obtaining

Doctor/Doctor's office must call

Receiving

Faxed to Doctor's office

Returning

Mail

Doctor's Action

Complete section, sign, attach prescription

Applicant's Action

Complete section, sign, attach required documents

Decision Communicated

Patient notified in writing

Decision Timeframe

7-10 business days

Medication

Amount/Supply

Up to 30 day supply

Sent To

Patient's home

Delivery Time

Shipped overnight

Refill Process

Varies per medication

Limit

Varies per medication

Re-application

New application, new documentation yearly

Additional Information

Updated November 07, 2016

Last Modified 10/05/2016 10:36:00

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